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- PATIENTS AND METHODS
The Chronic Care model and the Institute of Medicine have established self-management programs as a necessary component of good care for persons with chronic disease (1–5). Within the model, such programs are known as self-management support, which is how providers and systems support patients in their self-management efforts. Over the past 2 decades, there have been many examples of effective self-management support (2, 6). Most of these programs have been disease specific, whereas a few are more generic. One of the major questions arising from past self-management studies is how to best understand the effectiveness of different programs. In this report, we examine the specific issue of the relative effectiveness of a disease-specific self-management program versus a generic self-management program for individuals with arthritis and discuss the policy implications for the findings.
The Arthritis Self-Management Program (ASMP), also known as the Arthritis Self-Help Course and Challenging Arthritis, is now more than 25 years old. It has been found to be useful for persons with arthritis (7–9).
In the past 10 years, the Chronic Disease Self-Management Program (CDSMP), also known as the Expert Patient Program, has been developed and evaluated (8, 10, 11). Unlike the ASMP, the CDSMP is a generic program that individuals with many different types of chronic conditions attend at the same time. In an initial randomized study, persons with arthritis who attended the CDSMP workshop showed improvements in health behaviors and health status (12). Both the ASMP and the CDSMP are large programs in the United States, Great Britain, Australia, New Zealand, and Canada.
Whether a disease-specific self-management program would have advantages over a more generic program remains an open question, although intuitively this would seem to be the case. This is especially true because a large percentage of persons with arthritis also have comorbid conditions (13).
Although many individuals with arthritis have participated in CDSMP studies, we have not been able to evaluate the distinct outcomes for these individuals in the CDSMP. We do not know if their arthritis was the reason for attending the program or was, as we suspect, often a secondary comorbid condition. Because of the wide dissemination of both of these programs, we have often been asked about the relative merits of the ASMP and the CDSMP but have not been able to give an evidence-based response. In the current study, we hypothesized that both programs would be effective for individuals with arthritis, and that there would be few differences in effectiveness at 4 months and 1 year.
- Top of page
- PATIENTS AND METHODS
In previous trials, patients with arthritis randomized to the ASMP were found to have positive outcomes compared with those randomized to continue with usual care. Subsequently patients with arthritis randomized to the CDSMP had better outcomes compared with patients who remained in usual care. The current study did not include a usual care group, but the results for both ASMP and CDSMP participants were positive and similar to what we had found in the previous studies (8, 12).
The comparative data from the current study suggest that the disease-specific ASMP has advantages over the more generic CDSMP. This was especially true at 4 months. However, these advantages had lessened slightly by 1 year. It must be noted that one cannot accurately compare the significance (P values) of the CDSMP versus ASMP outcomes at 4 months or at 1 year (Tables 3 and 5) because the number of CDSMP participants with arthritis was less than half that of ASMP participants, thus reducing the statistical power for CDSMP. However, one can compare the unadjusted magnitude of the change scores for the ASMP or CDSMP participants, or look at the least-squared adjusted means for the 2 programs from the multivariate analyses (Tables 4 and 6).
The programs can also be compared by examining the effect sizes of the 2 programs. If an effect size of 0.2 is considered a minimally important difference, then 6 outcomes were improved for the ASMP participants at 4 months, whereas only 3 outcomes showed such improvement for the CDSMP participants. At 1 year, ASMP participants (using the criteria of effect size ≥0.2) showed at least minimal improvement for 5 outcome variables. The CDSMP participants showed this level of improvement for 4 outcome variables. Thus, the level of differences between the 2 programs was reduced slightly at 1 year.
The final question, which this study sought to answer, is one of policy. Should organizations and health care systems offer disease-specific programs or generic programs? Here the answer is not as clear as we might like. First, these findings may not be similar for individuals with chronic conditions other than arthritis; we do not know if patients with heart disease will do better in a heart disease self-management program than in the CDSMP. Based on the data from this study, we would suggest that for individuals whose major symptom is arthritis, the ASMP is initially (4 months) more effective than the CDSMP, although some of these differences are lost by 1 year.
However, to sustain a disease-specific program, one must have a large enough patient base. It may be that by offering a generic program, more individuals can be reached at less cost. In addition, a generic program may actually reach larger numbers of persons with arthritis because arthritis is one of the most common comorbid conditions.
Our sample was a predominantly female, elderly population with a high incidence of other diseases and relatively high education level. The finding may not apply equally well to patients with arthritis with, for example, lower education levels. The present study did not include enough participants to look at men alone or those with low education alone. Future studies might be necessary to see if there are similar differences between the same programs among varying age, ethnic, sex, and educational groups.
In conclusion, self-management support such as the ASMP and CDSMP is helpful for persons with arthritis. How each program is used individually or together depends on the health care provider and the patient base. As with other treatments, the best treatment for all concerned is often a tradeoff between individual need, system ability, and costs.